Driving rules and assessment for older people

The incidence of medical conditions that can affect safe driving increases with age. Older people should be regularly assessed for their fitness to drive and prepared early for the possibility that they may not be able to drive, at some point in the future. This should occur not only at the time of driver licence renewal, but whenever medical conditions or medications change that may impact on driving ability and safety.

Older people should be regularly assessed for their fitness to drive, especially when their medical conditions
or medications change

A medical certificate is required for driver licence renewal in people aged over 75 years

If GPs are uncertain about a patient’s fitness to drive, they may refer them to an occupational therapist
trained in driving assessment

Prepare patients early for the possibility that they may become unfit to drive at some point in the future

There are several transport subsidies available for older people; make sure patients are aware of these options

Age-related factors can impact on driving ability

Older age itself is not a contraindication to driving, with thousands of licence holders in New Zealand aged over 90
years. However the incidence of medical conditions that can affect safe driving increases with age, e.g. dementia, stroke
and cardiovascular disease. Other age-related factors that may impair driving include earlier onset of fatigue, slowed
responses, visual problems, impaired cognitive function and impaired mobility.

In New Zealand, the two main causes of fatal crashes in 2008 were loss of control (40%) and driving too fast for the
conditions (34%). Illness or disability was attributed as the cause of 6% of fatal crashes. Of these incidents, one-third
were due to illness with no warning and another third to impaired ability due to old age.1

Being able to drive is extremely important for many older people, allowing them to remain independent and mobile. However
holding a driver licence is not a right and the balance must be made, between retaining quality of life for the older
person, and keeping them and others safe on the roads. Primary care plays an important role in helping to recognise when
the time has come to review the driving ability of an older person.

Driver licence renewal process for older people

In New Zealand, a driver licence is valid for ten years up to the age of 75 years. After this, a licence is valid for
five years only, then must be renewed every two years over the age of 80 years.

A medical certificate is required for driver licence renewal in people aged over 75 years and this is completed by
a GP. After completing a clinical assessment the GP may recommend one of the following:

The patient is medically fit to drive and does not require further assessment.

The patient is medically fit to drive with specified conditions.

The patient is medically fit to drive but an on-road safety test with a testing officer is recommended.

The patient is in need of further assessment before they can be deemed medically fit to drive (patient may be referred
for specialist medical assessment or to an occupational therapist for driving assessment).

The patient is not medically fit to drive.

GPs may recommend that conditions are imposed on a patient’s driver licence to improve safety such as automatic
vehicle only, no night driving, driving within 10 kilometres of home, or after 9.00 a.m. and before 3.00 p.m. There is
only space for 20 characters on the back of the photo licence for each special condition. It is important to ensure that
any special recommended conditions for a licence are able to be checked by the traffic enforcement agency.

Advocating for patients who have been deemed unfit to drive
If a patient has been deemed unfit to drive according to New Zealand Transport Agency Standards, but their
specific circumstances mean this is inappropriate, the GP may write to the Chief Medical Advisor for consideration of
the case. A full licence may be granted in some situations, or a licence with restricted conditions may be given, such
as a requirement for annual medical review. In the case of commercial drivers, a supporting report from a medical specialist
is usually required.

Regularly assess older people for fitness to drive

A medical assessment is required for licence renewal in people aged over 75 years. However older drivers should be frequently
assessed for fitness to drive, especially when their medical conditions or medications change.

It is often difficult to address the topic of driving fitness. If there is a danger of destroying a therapeutic relationship,
a GP may consider referring the patient to another medical practitioner for assessment. If a patient is generally medically
fit but there is still concern about their driving ability due to frailty, possible cognitive decline or a specific medical
condition, they may be referred to a specially trained occupational therapist for a driving assessment. This recommendation
can also be indicated on the driver’s medical certificate if the patient is renewing their driver licence.

The specific type of driving assessment is dependent on the patient’s medical condition. As a rule an occupational
therapy driving assessment is only required, where there is a medical problem which impacts on the patient’s physical
or cognitive function, related to driving.

GP tip: Discussing driving fitness is often forgotten during
complex consultations. Make this part of your “safety net” checklist at the end of each consultation. This
is especially important in the case of an acute illness where the diagnosis has not been confirmed and when a new drug
has been prescribed. Don’t forget to record driving advice in the patient notes.

Signs that may indicate decline in an older person’s driving abilities

GPs and practice nurses should be alert to signs which may indicate that an older person is having difficulty with driving.
The patient themselves, or their family members, may comment on the following:

Driving at inappropriate speeds – too fast or too slow

Asking passengers to help check if it is clear to pass or turn

Responding slowly to or not noticing pedestrians, cyclists or other drivers

Ignoring, disobeying or misinterpreting road signs and traffic lights

Failing to give way to other vehicles or pedestrians that have the right of way

Other significant conditions such as severe respiratory illness or malignant disease

Refer to the New Zealand Transport Agency “Medical aspects of fitness to drive” guide (supplied to all GPs)
for specific requirements and standards for testing.

Quick driving assessment

Consider if a new medical condition, change in medical condition, new medication or change in dose has the potential
to compromise driving performance.

Does the change affect any of the following:

Physical - weakness, slow or limited movement?

Sensory - visual loss, limited feeling in limbs?

Cognitive/perceptual - slowed thinking, decreased attention?

Emotional - anxiety, panic reactions?

Questions to consider asking include: Is anyone concerned about your driving? Do you feel less confident about driving?
Have you restricted your driving habits? Do you think you are a safe driver?

Simply observing the patient during the consultation may make it unnecessary to assess some of these functions, but
consider examination of cognition, vision, motor skills and sensation.

Legal obligations of a medical practitioner in relation to driving fitness

The two legal obligations that medical practitioners must adhere to are:

Advise the New Zealand Transport Agency (via the Chief Medical Adviser) of any individual who poses a danger to public
safety by continuing to drive when advised not to.

Consider the guide “Medical aspects of fitness to drive” when conducting a medical examination to determine
if an individual is fit to drive.

N.B. “Medical aspects of fitness to drive: A guide for medical practitioners”, provides
information for GPs about situations in which driving ability should be assessed. This is a guide to good practice rather
than a set of legally enforceable criteria.

Discussing being unfit to drive

Prepare patients early for the possibility that they may become unfit to drive at some point in the future. Allow the
patient time to consider other transport alternatives that they may need to adopt. Changes could be made prior to a complete
cessation of driving, including reducing the amount of time driving, avoiding peak traffic periods, avoiding highways
and busy roads or avoiding driving at night time. Patients are usually open to suggestions of ways they can remain safe
drivers.

If a patient has been deemed unfit to drive, discuss the reasons for this and when the decision may be reviewed (if
at all). It is often a good idea to have this discussion in the presence of a supportive family member or friend. Consider
putting the decision in writing for the patient, especially if long-term cessation of driving is advised.

If the patient agrees that they will not drive or will only drive under specified conditions, no further action is required.
If the patient does not accept the advice and is likely to continue to drive, the New Zealand Transport Agency should
be advised (see sidebar “Legal obligations”).

In general, men find it more difficult than women to adjust to life without driving. Being without a driver licence
is more of a threat to older men’s independence and self-image. Be aware of these gender differences, and how the
loss of a driver licence can affect others, that rely on that person for transport.

Driving restrictions for medical conditions common in older people

Table 1 contains a summary of driving restrictions applicable to medical conditions commonly seen in older people. For
a full list of conditions and restrictions, refer to “Medical aspects of fitness to drive” guide.

Table 1: Summary of driving restrictions applicable to medical conditions commonly seen in older people

Private vehicle or motorcycle licence

Heavy transport/passenger endorsement

Cerebrovascular accident (CVA)

Should not drive for at least one month and not until clinical recovery is complete,
with no significant residual disability

Should not drive (exceptions may be granted for current licence holders)

Transient ischaemic attack (TIA)

Single TIA - should not drive for at least one month
Multiple TIAs - may return to driving after three months, following investigation and treatment of condition

Single TIA - should not drive for at least six months.
Multiple TIAs - should not drive (exceptions may be granted)

Neuromuscular disorders including Parkinsonism

Driving should cease when there is doubt about the ability to control the vehicle
when rapid response is required

Should not drive (exceptions may be granted if mild symptoms only)

Dementia and other cognitive impairments

Driving should cease when impairments may affect the ability to drive safely

Should not drive

Angina pectoris

Proven or suspected - should not drive if angina pectoris at rest or on minimal exertion

Same as private class

Acute uncomplicated myocardial infarction

Should not drive for at least two weeks (return to driving subject to specialist assessment)

Should not drive for at least four weeks (return to driving subject to specialist
assessment)

Severe hypertension

Should not drive if treatment causes symptomatic postural hypotension or impaired
alertness

Should not drive if anticoagulation cannot be maintained at the appropriate degree
for the underlying condition

Same as private class

Cardiac failure and cardiomyopathy

Should not drive if dyspnoea present on mild exertion (return to driving subject to
specialist assessment)

Should not drive (exceptions may be granted but not for hypertrophic cardiomyopathy
or syncope)

Type 2 diabetes

Generally considered fit to drive unless severe hypoglycaemic
unawareness* in
which case, should not drive until successfully managed

Dietary control only - generally considered fit to drive
Oral agents - generally considered fit to drive, but may be some licence conditions
Insulin - some considered fit to drive, but likely to have licence conditions, specialist assessment
necessary
Severe hypoglycaemic unawareness - generally considered unfit to drive

Severe chronic mental disorder (including depression)

Driving should cease when the ability to drive safely may be impaired (return to driving
subject to satisfactory treatment and usually after an observation period of six months)

Same as private class, but usually an observation period of 12 months before a return
to driving

Medications and alcohol may have an enhanced negative effect on driving in older people

Medications that cause drowsiness or distraction can have a significant impact on driving ability. Age-related changes
in drug metabolism can enhance the effect of these medications in older people.

When starting any new medication in an older patient, consider what affect it may have on their driving ability. Adverse
effects are often worse in the first few days of a new medication. Consider advising the patient to avoid driving until
they know how a medicine will affect them.

Benzodiazepine use is most often associated with an increased risk of injury causing accident among older drivers. Other
medications that may affect driving ability include opiates, antidepressants, antipsychotics, some antihistamines and
some cold and flu preparations.

The effects of alcohol may also be enhanced in older people. This should be explained to older patients and recommended
to them that they have minimal or no alcohol intake prior to driving.

Occupational therapist driving assessment

Patients may be referred to a specially trained occupational therapist for a driving assessment if a GP is unsure if
they are medically fit to drive.

The assessment consists of both off-road and on-road testing. As part of the off-road assessment, the occupational
therapist will check vision, range of movement, strength, sensation, coordination, judgement, memory, directional orientation,
movement and decision making times, cognition and comprehension and knowledge of road rules and signs.

Occupational therapists trained in driving assessments are skilled in distinguishing between driving behaviours that
are existing routine habit, and those that are the result of a medical condition, especially where cognitive impairment
is evident and/or there is a physical deficit.

If a patient’s off-road testing is satisfactory, the occupational therapist will proceed to an on-road test.
This may include driving on both urban roads and highways, driving through controlled and uncontrolled intersections,
parking and manoeuvring.

The occupational therapist will send a report to the GP who requested the assessment, with a recommendation as to whether
the patient is medically fit to drive. The GP then makes the final decision as to whether a medical certificate is issued.

Most occupational therapists undertaking driving assessments work in private practice. A full off-road and on-road
assessment can cost between $380 and $550 with the average being around $400 to $450. This also includes the presence
of a driving instructor, whose role is to risk manage the drive and intervene, if required.

Transport subsidies and specialised equipment are available for older people

Mobility scooters and power chairs

Mobility scooters and power chairs (motorised wheelchairs) may be a suitable option for older people who are no longer
able to drive a motor vehicle, have limited distance mobility outside the home and who are sufficiently cognitively capable.
A driver licence is not required to operate these devices.

A mobility scooter costs approximately $2000 - $7000 to purchase. Second-hand scooters are available privately and from
some retailers. Approximately 250 Lottery Grants are awarded each year for the purchase of a scooter. Some areas offer
schemes (e.g. Wellington City Mobility) which provide a number of free scooters for short-term use.

Many local councils run training courses for using mobility scooters or power chairs. Contact the Road Safety Coordinator
at the nearest council.

N.B. Lottery grants are also available for funding vehicle modifications for individuals with physical
disabilities to drive or travel as a passenger.

Total Mobility taxi scheme

The Total Mobility taxi scheme offers subsidised transport for people with disabilities (mobility, sensory, psychiatric
or intellectual) who have difficulty using public transport. After assessment for eligibility, a person will receive up
to 50% discount on door-to-door transport (usually a taxi).

This scheme may not be available in all areas (e.g. rural) and there are local variations on the amount of discount
applied. Contact the nearest local or regional council or Age Concern office.

Free off-peak public transport

SuperGold Card holders may be eligible for free off-peak public transport (9am to 3pm, after 6pm, weekends and public
holidays). There are local variations to the definition of off-peak travel and types of transport available therefore
contact local councils for information.

Mobility Parking permit

The Mobility Parking permit allows users to park in accessible marked parks. Permit holders may also use standard car
parks and metered spaces for longer than the stated times. The scheme is run by CCS Disability Action in partnership with
local councils. To be eligible, a person must rely on mobility aids such as crutches, walking sticks or a walking frame,
or be unable to walk for more than 200 meters unaided due to their condition. Permits cost $45 for five years or $30 for
a temporary 12 month permit. GPs must certify applications.

For more information contact: CCS Disability Action - 0800 227 2255

National travel assistance scheme

DHBs provide funding for travel assistance to enable people to attend specialist health and disability support services
i.e. if a specialist refers a patient to another publicly funded specialist, transport costs of getting there (and accommodation
if applicable) may be covered. This does not apply to General Practice visits.

Medical conditions which require driving assessment

Medical fitness to drive should be assessed in the presence of the following conditions:

Resources

The New Zealand Transport Agency has many downloadable resources on its website for older people including: Renewing
driver licences at age 75 and over, supporting older drivers, keeping moving, guide to the on-road safety test and how
to use a mobility scooter or power chair safely. See www.nzta.govt.nz/resources

To find the nearest occupational therapy driving assessment service, contact Enable New Zealand on 0800 171 981 or
the New Zealand Association of Occupational Therapists on (04) 4736510.

Acknowledgement

Thank you to Kevin O’Leary, Occupational Therapist, Kevin O’Leary and Associates, Wellington,
for expert guidance in developing this article.